Addressing Mental Health Concerns in
Children and Adolescents:
How to Make a Difference
Barbara Frankowski, MD, MPH, FAAP
American Academy of Pediatrics
Darcy Gruttadaro, JD
National Alliance on Mental Illness
Judith Palfrey, MD, FAAP
American Academy of Pediatrics
National Center on Community Based Services
Objectives
Participants will be able to:
• Understand the mental health needs of
children and youth including the impact on:
– families
– primary care practices
– state systems
• Identify strategies to address mental health
concerns
• Work on Solutions!
Data Makes the Case
• We are beyond a one-child-at-a-time
approach.
• Mental illness is a public health issue.
• It takes a village….
Epidemiology of Pediatric Mental
Health Conditions
• 9.5-14.2% of children birth to 5 have S-E problems interfering
with functioning
• 21% of children and adolescents in the U.S. meet diagnostic
criteria for MH disorder with impaired functioning
• 16% of children and adolescents in the U.S. have impaired MH
functioning and do not meet criteria for a disorder
• 13% of school-aged, 10% of preschool children with normal
functioning have parents with “concerns”
• 50% of adults in U.S. with MH disorders had symptoms by the
age of 14 years
MH Conditions in Children with Chronic
Illness: Hidden Morbidity
• Children with chronic illness 2X more likely to
have psychosocial dysfunction
• Children with MH problems (and their parents)
are higher users of healthcare services in general
(eg, ED use)
Impact on Families
• Families are completely unprepared to have
MI hit - the topic alone is loaded – stigma,
blame and shame.
• The path from onset to acceptance of MI in a
child can be long and difficult.
• The diagnosis impacts the whole family.
• There are predictable stages of emotional
reaction for families.
Impact on Families
The impact of undiagnosed and untreated MI:
• Symptoms cause poor functioning at a critical
developmental time (in school, with friends and at
home);
• Children often fail to develop the social, functional
and academic skills they need to succeed in life;
• Behaviors are often unpleasant and irritating; and
• Ultimately, children with MI are robbed of their
childhood.
Impact on Families
Accessing MH services:
• Silos lead families to seek services from
multiple systems, often unsuccessfully;
• Workforce shortage and wait lists lead to lag
time in getting a child services and support;
and
• A full array of effective services are rarely
available and are often targeted at the child
and not at the whole family.
Impact on Families
• Parents often miss or leave work – get
called to come and pick up their child.
• Families face challenges in finding
resources to help them cope.
• Families are often isolated and feel very
alone when their child is diagnosed with a
MI.
Impact on Primary Care
• “By 2020-2030, it is estimated that up to 40% of patient visits
to pediatricians will involve long-term chronic disease
management of physical and psychological/behavioral
conditions.”
• “In 2020 pediatricians have a wider array of skills including
more in-depth knowledge of, and comfort treating,
behavioral, developmental, and mental health concerns.
Medical education includes mental health interventions,
which are now an established aspect of pediatric care.”
-AAP Task Force on the Vision of Pediatrics 2020
Impact on Primary Care
Advantage/Potential Roles of Primary Care Clinicians in MH & SA Care
• Longitudinal, trusting relationship
• Prevention
• Early identification / screening
• Early intervention / engagement
• Diagnostic assessment
• Specific treatment
• Referral / collaborative care (with MH / SA professionals)
• Monitoring progress in care
• Care coordination (as for other CYSHCN)
Impact on Primary Care
Barriers to Enhancing MH Care in Primary Care Settings
• Ambivalence / variability
• Discomfort
• Time constraints
• Poor payment
• Variable access to MH specialty resources
• Administrative barriers to MH services
• Limited information exchange with MH specialists
• Children and families’ reluctance to seek MH specialty care
Impact on State Systems
• Public MH system chronically underfunded
• Focuses on individuals with most severe
impairment
• Little support for prevention
• Little support for services to children with
emerging or mild/moderate conditions
Workforce Issues
• Insufficient #s of child MH specialists, especially,
child psychiatrists and providers of services to young
children
• Little support for prevention or services to children
with emerging or mild/moderate conditions
• Administrative barriers in insurance plans limit
access to existing providers
• Many forces leading families to seek help for MH
problems in primary care
• Pediatric workforce faces many challenges
Family-Centered Community-based System of Services
for Children and Youth
Perrin JM et al. Arch Pediatr Adolesc Med 2007;161:933-936
Strategies: What Works for Families
At the individual family level:
• Understand the early stages of emotional turmoil for
families;
• Help the family to understand how to access MH
services and supports;
• Provide the family with resources – they will want to
learn more; and
• Link the family with a family advocacy organization
so that they know they are not alone.
Strategies: What Works for Families
At the systems level:
• Develop and build “no wrong door” policies;
• Support the development of a full array of effective
MH services and supports;
• Support workforce development and innovative
practice models;
• Support early ID and early intervention;
• Support collaborative efforts across child-serving
systems (PC, MH, schools, CW, JJ and more); and
• Get to know and refer families to family advocacy
organizations for support, education and advocacy.
Strategies: What Works for Primary Care
• Primary Care
– Bright Futures Guidelines for Health Supervision of Infants,
Children, and Adolescents, 3rd Edition
– Mental Health Task Force:
• Chapter Action Kit
• Special Article: Reducing Administrative & Financial Barriers to
Access & Collaboration
• Policy Statement: MH Competencies for Pediatric Primary Care
• Supplement: Enhancing Pediatric MH Care
• MH Clinician’s Toolkit
– New Models of Care
Strategies: What Works for Primary Care
…is a set of principles,
strategies and tools that
are theory - based,
evidence - driven, and
systems - oriented, that
can be used to improve
the health and well-being
of all children
Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics
Strategies: What Works for Primary Care
The Bright Futures Guidelines, 3rd Edition
• Themes:
– Promoting Mental Health
• In the Visits:
– Priorities for the Visit
– Observation of parent-child interaction
– Surveillance of development
• Developmental milestones
• Developmental tasks
– Universal and selective screening
– Anticipatory Guidance
• How you might do it:
– See the Introduction to the Visit Section
Strategies: What Works for Primary Care
Task Force on Mental Health (TFMH)
• Facilitate health system changes
• Build clinician competencies/competence
• Incrementally change practice
• Build a strong coalition
Strategies: What Works for Primary Care
Strategies for System Change in Children’s Mental Health:
A Chapter Action Kit
Strategies to:
• Partner with Families
• Assess the Service Environment
• Collaborate with MH Professionals
• Educate Chapter Members
• Partner with Child-Serving Agencies
• Improve Children’s MH Financing
Available at www.aap.org/mentalhealth
Strategies: What Work for Primary Care
Improving MH Services in Primary Care:
Reducing Administrative & Financial Barriers to Access & Collaboration
• Outlines issues and potential
solutions
• Makes recommendations to
insurance purchasers, payers,
& managed behavioral health
organizations
American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics, American Academy
of Pediatrics Task Force on Mental Health. Improving Mental Health Services in Primary Care: Reducing Administrative and
Financial Barriers to Access and Collaboration. Pediatrics, Apr 2009; 123:1248-1251
Strategies: What Works for Primary Care
The Future of Pediatrics:
MH Competencies for Pediatric Primary Care (policy statement)
•
•
•
•
System-Based Practice
Patient Care
Medical Knowledge
Practice-Based Learning &
Improvement
• Interpersonal & Communication
Skills
• Professionalism
Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. The Future of
Pediatrics: Mental Health Competencies for Pediatric Primary Care. Pediatrics, July 2009; 124:410-421.
Strategies: What Works for Primary Care
Enhancing Pediatric MH Care:
Report from the AAP TFOMH
• Strategies for Preparing a Community
• Strategies for Preparing a Primary Care Office
• Algorithms for Primary Care
Supplement (including several free tools) is available at
www.aap.org/mentalhealth
Task Force on Mental Health. Enhancing Pediatric Mental Health Care Care: Report From the American Academy of Pediatrics
Task Force on Mental Health. Pediatrics, June 2010; 125;S69-S125.
Strategies: What Works for Primary Care
Addressing MH Concerns in Primary Care:
A Clinician’s Toolkit
3 approaches to using the toolkit:
• Preparation of the Practice (inventory)
• Step-by-step clinical process (algorithms)
• Guidance in managing common presenting
symptoms (cluster guidance)
• Order from AAP Bookstore:
http://tinyurl.aap.org/pub112382
• Virtual Tour: www.aap.org/pcorss/demos/mht.html
Strategies: What Works for Primary Care
Practice Readiness Inventory
• Community Resources
• Health Care Financing
• Support for Children &
Families
• Clinical Information
Systems/Delivery System
Redesign
• Decision Support for Clinicians
Algorithm A: Promoting Social-Emotional Health, Identifying Mental Health and Substance Use
Concerns, Engaging the Family, and Providing Early Intervention in Primary Care
A2a
A1a
Legend
Collect and review pre-visit
data
= Start
Visit (prenatal, nursery, or
primary care) scheduled
A3a
= Action / Process
Provide initial clinical
assessment; observe
child-parent interactions.
A1b
= Decision
A4a
Acute care visit
Acknowledge and reinforce
strengths
= Stop
A2b
A7a
Incorporate brief
mental health
update
A5a
A6a
Return to routine
health supervision
Provide anticipatory
guidance for age per Bright
Futures, Connected Kids, or
KySS
No
Concerns
(symptoms, functional
impairment, risk behaviors,
perceived
problems)?
A7b
A3b
Return to acute
care visit
Concerns?
No
No
A12a
A11a
Collect and
review data from
collateral sources
Yes
Further
diagnostic
assessment
needed?
Yes
A10a
Provide initial
intervention;
facilitate referral
of family member
for specialty
services, if
indicated.
A8a
No
Yes
A9a
A13a
Proceed to
Algorithm B
Yes
A6b
Facilitate referral
for specialty services or
emergency facility; reenter algorithm at
appropriate point (or
A1a).
A5b
A4b
Emergency?
Return to acute
care visit.
Plan to enter
algorithm at
step A1a.
Yes
Emergency?
No
Facilitate referral
for specialty services or
emergency facility; reenter algorithm at
appropriate point (or
A1a).
Algorithm B: Assessment and Care of Children with Identified SocialEmotional, Mental Health (MH) or Substance Abuse (SA) Concerns, Ages 0-21
B1a
B1b
Child receiving MH/SA
specialty services
Further assessment
needed for MH/SA concern
B2a
B5a
B3a
Who will provide further
assessment?
Provide MH
assessment
Primary
Care
Specialist
Facilitate referral to
specialist(s) for
further assessment
B4a
B6
B2b
Interpret findings to family (and youth
as appropriate); convey hopefulness
about treatment and recovery.
B13
Collect reports and
recommendations
B12
Return to routine
health supervision &
monitor for further
issues
Is concern
persisting?
No
Yes
B8
B7
B11
Implement chronic care
protocol
Specialty care
needed?
Legend
Facilitate involvement of
specialist(s)
Yes
No
= Start
B10
B9
= Action / Process
= Decision
= Stop
Collaboratively
develop a familycentered care
plan
Collect reports and/or
convene team to review
Strategies: What Works for Primary Care
Cluster Topics
• Inattention and impulsivity
• Depression
• Anxiety
• Disruptive behavior and aggression
• Substance use
• Learning difficulties
• Symptoms of social-emotional problems in children birth
to 5
Strategies: What Works for Primary Care
New Models of Care
• New roles of staff within primary care
• New applications of technology
• Collaborative arrangements with community-based
MH / SA / developmental specialists
• Co-location of specialist(s)
• Integration of a specialist(s)
• Child psychiatry consultation by telephone,
telemedicine, face-to-face
Promising Practices within State Systems
• Mental health consultations to pediatric primary care
physicians
– Mass Child Psychiatry Addess Project (MCPAP)
– Oregon
– Ohio
• Telehealth
• Policy: North Carolina
– Reimbursement of unmanaged visits
– Rosie D
• Maternal Depression
Promising Practices within State Systems
• Chapter Grants to Implement the Chapter
Action Kit (CAK)
– Alabama, Arkansas, Kansas, Mississippi, & Oregon
– Goal: plan/implement one or more of the
strategies outlined in the CAK
– Reports available at:
www.aap.org/mentalhealth/mh2ch.html
Break Out: Part 1
• Break into groups of 5 – 8 participants
• 20 minutes: collaboration exercise
–Discuss strengths and challenges of state
activities around mental health
• 20 minutes: group reports and Q&A
–Select a group member who will report
out on main themes from discussion
Role of the Public Health Community….
Provide the Population Perspective
• Publicize MH trends
• Identify and address risk
factors for childhood mental
illness
• Identify and enhance
protective factors
Expand Partnerships
•
•
•
•
•
•
•
•
•
•
Consumers (e.g., NAMI, Federation of Families)
Professional associations of MH providers
Academic pediatricians and psychiatrists
Area Health Education Center
Primary care clinicians (peds, fam med, NP, PA)
Early Intervention system
State department of ed / local school systems
Juvenile Justice / DSS
Medicaid / SCHIP agencies
Insurers
Increase Collaboration and Coordination
Across “Silos”
Examples:
• Community protocols (e.g., psychiatric
emergencies, ADHD)
• MH resource guide
• Mixers
Foster Policies Favorable to MH
Integration in Primary Care
Examples:
• Bright Futures implementation
• Incentives for co-locating MH professional in
primary care setting
• Payment (especially Medicaid and SCHIP) for
all facets of mental health care
Champion the Cause of Prevention
Examples:
• Bright Futures
• Nurse-family Partnership (Olds model)
• Evidence-based parenting programs
• Environmental health (lead, mercury…)
• Healthy lifestyles (nutrition, physical activity,
stress management, sleep…)
Improve Early Identification
Examples:
• MH screening at all ages
• Warning signs (child and family)
• Training of school / public health personnel
• Child care training / consultation
• Transition from EI program to schools
Incorporate MH Services / Perspective
into Public Health Programs
Child service
coordination
Disaster
preparedness
Maternity care
coordination
Mental
Health
High risk
obstetric
clinics
Child care
consultation
School
Health (!!!)
Educate Public
• Examples:
• Parent education (anticipatory guidance,
building resilience, early signs of distress)
• Public campaign addressing stigma
Advocate for Resources and System Changes
• Examples:
• Fully implement insurance parity
• Subsidize child psychiatrists (e.g., consultation
network)
• Incorporate MH care coordination into Early
Childhood Comprehensive Services early
childhood health plan
Monitor Impact of Changes
•
•
•
•
•
•
Participating MH providers
Claims data / Medicaid & SCHIP
Youth Risk Behavior Survey
Persons receiving MH services by race / ethnicity
Abuse / neglect rates; out-of-home placements
Educational outcomes (drop-out, suspension,
graduation rate)
• Juvenile crime rate
• Injuries
• Consumer / provider opinion
Break Out: Part 2
• Break into groups by state (if possible)
• 30 minutes: action plan exercise
– Put together an action plan to address mental
health concerns in children and adolescents
– If already done an action plan in your state join a
group and provide input on successes and
challenges
• 20 minutes: group reports and Q&A
– Select a group member who will report out on main
themes from discussion
Contact Information
American Academy of Pediatrics
National Alliance on Mental Illness
Staff:
Staff:
Stephanie Nelson, MS, CHES
snelson@aap.org
Darcy Gruttadaro, JD
darci@nami.org
141 Northwest Point Blvd
Elk Grove Village, IL 60007
Main: (800) 433-9016
Fax: (847) 228-7320
3803 N. Fairfax Dr., Ste. 100
Arlington, VA 22203
Main: (703) 524-7600
Fax: (703) 524-9094
Web site:
Web site:
www.aap.org/mentalhealth
Email:
mentalhealth@aap.org
www.nami.org
Questions?
Acknowledgements
AAP TFMH Members
• Jane Foy, MD, Chairperson
• Paula Duncan, MD
• Barbara Frankowski, MD, MPH
• Kelly Kelleher, MD, MPH
• Penelope Knapp, MD
• Danielle Laraque, MD
• Gary Peck, MD
• Michael Regalado, MD
• Jack Swanson, MD
• Mark Wolraich, MD
Acknowledgements
TFMH Consultant Members
• Alain Joffe, MD
Committee on Substance Abuse
• Margaret Dolan, MD / Pat O’Malley, MD
Committee on Pediatric Emergency Medicine
• James Perrin, MD
Council on Children with Disabilities
• Thomas McInerny, MD
Committee on Child Health Financing
• Lynn Wegner, MD
Section on Developmental and Behavioral Pediatrics
• Eileen Ouellette, MD, JD
Acknowledgements
TFMH Liaison Members
• Terry Carmichael, MSW
National Association of Social Workers
• Darcy Gruttadaro, JD
National Alliance on Mentally Illness
• Garry Sigman, MD
Society for Adolescent Medicine
• Myrtis Sullivan, MD
National Medical Association
• L. Read Sulik, MD
American Academy of Child and Adolescent Psychiatry
Organizations Involved
• Liaisons to TF (AACAP, NASW, NAMI, SAHM, NMA)
• American Psychological Association
• Association of Maternal & Child Health Programs
• Carter Center Mental Health Program
• Centers for Disease Control and Prevention
• CityMatCH
• Family Voices
• Federation of Families for Children’s Mental Health
Organizations Involved
• Hogg Foundation for Mental Health
• Institutes of Medicine
• Maternal and Child Health Bureau
• National Alliance on Mental Illness
• National Business Group on Health
• National Institute for Health Care Management
• Substance Abuse and Mental Health Services
Administration